NDIS Referral Form

"*" indicates required fields

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REFERRER DETAILS

Your Name*

Date of Referral

Organisation

Your relationship to the participant?*

Support Coordinator

Allied Health Practitioner

Other

Other*

Your Contact Number*

Your Email*

Do you wish to receive courtesy reminders of the participants upcoming session?

Email(Prior)*

48 hours prior

Yes

SMS(Prior)*

24 hours prior

Yes

Email*

Mobile Number*

How did you hear about us?

Social Media

Google

Existing Client

Family/Friend

Other Provider?

Other Provider

SERVICES REQUIRED

What services are you seeking on behalf of the participant?*

Positive Behaviour Support Please fill out the Positive Behaviour Support Referral form

Psychology /Therapy

Specialist Support Coordination L3

Psychology /Assessment

Social Worker /Therapy

How many sessions/hours?*

How much funding is available?

Frequency of services

Weekly

Fortnightly

Monthly

Other

Other(Frequency of services)

Preferred Days

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Times

Preference of Therapist

Male

Female

Preference of session location

Home Visit

School Visit

Soothing Minds Practice

Other

Other(Preference of session location)

PARTICIPANT DETAILS

Name*

Date of Birth*

Country of Birth*

Languages Spoken at Home

Is an interpreter required?

Yes

Language

Is the participant of Aboriginal or Torres Strait Islander Origin?*

Aboriginal

Torres Strait Islander

Both

Prefer not to say

Gender

Male

Female

Other

Other(Gender)

Residential Address, Suburb, State, Post Code*

Is the home address shared with other people?*

Yes

How many other people?

What is their relationship to the participant?*

Participant’s Contact #*

Participant’s Email Address*

Do you wish to receive courtesy reminders of your upcoming session?

Email*

48 hours prior

Yes

Email Address*

SMS*

24 hours prior

Yes

Mobile Number*

If Under 18 – What are the Parents’ / Guardians Names:

What are the Guardians’/Parents’ names? (1)

What are the Guardians’/Parents’ names? (2)

What are the Guardians’/Parents’ contact numbers? (1)

What are the Guardians’/Parents’ contact numbers? (2)

What are the Guardians’/Parents’ email addresses? (1)

What are the Guardians’/Parents’ email addresses? (2)

What are the guardians’ relationship to the participant? (1)

What are the guardians’ relationship to the participant? (2)

Do the participant wish to receive courtesy reminders of their upcoming session?

Email(Guardian 1)

48 hours prior

Yes

Email Address(Guardian 1)

Email(Guardian 2)

48 hours prior

Yes

Email Address(Guardian 2)

SMS(Guardian 1)

24 hours prior

Yes

Mobile Number(Guardian 1)

SMS(Guardian 2)

24 hours prior

Yes

Mobile Number(Guardian 2)

Are the parents separated?

Yes

N/A

Is there an Intervention or Family Court Order in place ?

Yes

N/A

Who is the emergency contact person:

Who is the Emergency Contact Name ?*

What is their Relationship to the Participant?*

Emergency Contact #*

Emergency Email Address*

What is/are the participant’s disability(ies)?*

Is the participant under Guardianship?*

Yes

Name(Guardianship)*

Email Address(Guardianship)*

Is the participant under Public Trustee?*

Yes

Name(Public Trustee)*

Email Address(Public Trustee)*

NDIS PLAN DETAILS

NDIS #*

Plan Dates

Start Date:*

End Date:*

How is the plan managed?*

Self-managed

NDIA managed

Plan Managed

Combined

Combined:*

Name of Plan Manager*

Contact name*

Contact number*

Email address*

Has Block Funding been applied to the plan?

Yes

List

Funding Period

Months

Funding Amount

Please click the + icon to add a row.

Do you have a copy of the current Plan?*

Yes

Upload Plan*

Max. file size: 128 MB.

Is it attached to this referral*

Yes

Are you able to provide a copy of the participants goals?*

Yes

If Yes, Please List below

Goal 1

Goal 2

Goal 3

Goal 4

Goal 5

SAFETY CHECK

Is anyone at the participant’s property aggressive or violent?*

Yes

Don’t know

Please specify*

Does anyone at the participant’s property have a criminal history?*

Yes

Don’t know

Please specify*

Does the participant have a positive behaviour support plan in place?*

Yes

Attached PBS if Yes*

Max. file size: 128 MB.

Is there a history of drugs or alcohol misuse at the property?*

Yes

Don’t know

Please specify*

Are you aware of any firearms being stored at the property?*

Yes

Don’t know

Please specify*

Are you aware of any occupant having an infectious disease (i.e., COVID-19, chicken pox / gastro, etc)?*

Yes

Don’t know

Please specify*

Are there any pets on the premises?*

Yes

Don’t know

Please specify*

Are there any other factors we should be aware of in regard to safety?*

Yes

Don’t know

Please specify*

OTHER SERVICES ENGAGED

What other services are already engaged?

Is there any other information that we need to consider or be aware of?